Mind & Muscle Medicine

Client Forms

Intake Form.pdf

This form is my health history form that all first time clients must fill out and bring to their first appointment! Parents of minors can fill this form out for their children and bring it to their first appointment as well.

 

MMM Privacy Policy Notice.pdf

This form is my Privacy Policy and is strictly for your own records. Feel free to print this out for yourself. You are not required to bring this form in to your appointment.

 

HIPAA FORM.pdf

This here is my HIPAA form. By signing this form you acknowledge that you've recieved my privacy policy and that you acknowledge that I will not share any of your own personal information with anyone else without prior consent. This form must also be printed and brought in on the day of your first appointment along with the health history form. Parents again you may fill this out for your child and bring it in to their appointment.

 

PRESCRIPT REFERRAL FORM.pdf

This is my Prescription / Referral form that I have created for clients who have been involved in an automotive accident or have sustained an injury on the job and are looking to have their Massage sessions covered by an insurance company.  This form must be printed and filled out by your Medical Doctor, a Physician or by a Chiropractor. This form can be brought in on the day of the first Massage post accident.

I will also need some additional information for billing purposes prior to the first appointment. So please have all information available when you contact me to schedule your appointment.

 

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